Step 1 of 10 10% Applicant InformationLegal Name of Company*Effective Date of Coverage*Mailing Address*City*State*Zip Code*Email Address* Years in BusinessInspection ContactInspection PhoneFederal ID#Type of Business Individual Corporation LLC Partnership Joint Venture Other (describe) Towing# of EmployeesPayrollReceiptsService Station# of EmployeesPayrollReceiptsAuto Mechanic# of EmployeesPayrollReceiptsAuto Body Shop# of EmployeesPayrollReceiptsUsed Car Sales# of EmployeesPayrollReceiptsRepossession# of EmployeesPayrollReceiptsTruckingIf Trucking Section Completed, Need Receipts# of EmployeesPayrollReceiptsOther# of Employees - otherPayroll - otherReceipts - other Description of Other OperationsFive Largest Clients For Which The Applicant Tows (including police, commercial and auto clubs)Client 1% of BusinessClient 2% of BusinessClient 3% of BusinessClient 4% of BusinessClient 5% of Business Is the Applicant involved in any repossession?YesNoIf yes, are the repossessions:voluntary?involuntary?How many repossessions are performed each month?Is the Applicant involved in anything other than towing?YesNo(If yes, please complete the Operation Section)Is applicant subsidiary of another entity or does applicant have any subsidiaries?YesNoIf yes, name and describe:Is there a formal safety program in operation?YesNoIf yes, number of meetings held monthlyWho conducts?(Include a copy of written safety program if one exists)Is there a written vehicle maintenance program in operation?YesNoAny vehicles leased, loaned or rented to others?YesNoIf yes, describe:Are these vehicles included in the attached schedule?YesNoIf no, explain why:Describe customized or special equipment OTHER THAN tow equipmentAny ICC filings required?YesNoAny PUC filings?YesNoIf yes, list below:NameAddressIf yes, does Applicant comply with all record keeping required by D.O.T.?YesNoIs MCS 90 Required?YesNoAuthority is granted in the name of:How many times monthly does the Applicant go beyond 50 miles?How many times monthly does the Applicant go beyond 200 miles?What cities?Does the Applicant carry Workers Compensation?YesNoPolicy PeriodInsurance co.What is the total number of vehicles the Applicant owns?Does the Applicant pick up or deliver customer’s cars other than Towing?YesNoIf yes, what radius of operation?Any Tire Sales?YesNoIf yes, receiptsHow does the Applicant dispose of used tires?Does the Applicant sell: New Tires Used Tires Any tire recapping or retreading performed?YesNoDoes the Applicant own or sponsor a car for racing?YesNoAny spray painting performed?YesNoIf yes, does Applicant have an UL approval spray booth?YesNoAny welding performed?YesNoIf yes, where is welding performed?Any protective screens used?YesNoUntitled First Choice Second Choice Third Choice Does the Applicant operate a service station?YesNoType of service station is: Self-Station Full-Service Both Does the Applicant operate: C-Store Car Wash Gallons sold annuallyHow many pumps does the Applicant have?Does the Applicant have a pollution liability policy on the underground storage tanks?YesNoDoes the Applicant do any dismantling or salvage?YesNoIf yes, how many number of units annually?Does the Applicant own a crushing machine?YesNoIf yes, describe here:Is public allowed to removed parts from vehicles?YesNoIs public allowed access to the salvage area?YesNoDo employees regularly use their own vehicles on company business?YesNoIf yes, explainDoes the Applicant have any public parking for which charge is made?YesNoIf yes, number of units per monthMonthly Receipts $Does Applicant have dogs on Premises?YesNoIf yes, numberIf yes, breedAre they Police/security trained Guard Dogs?YesNoAre “Beware of Dog” signs posted on gate?YesNoAre dogs penned up during business hours?YesNo Location 1Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 2Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 3Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 4Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsLocation 5Fenced (Y/N)HeightGates Locked at Night (Y/N)Watchman (Y/N)Alarm (Y/N)Avg. # of CarsDays of operation Mon Tues Wed Thurs Fri Sat Sun Normal hours of operation 0-12 hours 13-17 hours 18-24 hours If storing cars, for whom and under what circumstances are autos stored by the Applicant?Any change in operation, number of vehicles in the last 3 years?YesNoIf yes, please explain Attach copy of insurance company loss runsHas Applicant ever been cancelled or non-renewed?YesNo(Do not answer if risk is located in MO)If yes, why? Driver Information:Does the Applicant require written application?YesNoDoes the Applicant check reference?YesNoDoes the Applicant check driving records?YesNoDoes the Applicant check driving records?YesNoList any Towing Schools attendedHow are Drivers paid? Hourly Weekly Commission Salary Does the Applicant have a safe driving incentive program?YesNoIf yes, explain:Are the Drivers the Applicant’s employees?YesNoIf no, name of contractorDoes the Applicant use owner operators?YesNoHas the Applicant hauled anything other than vehicles within the past 3 years, (including incidental hauls)?YesNo If so, please complete the SECTION below.Items(s) HauledValueRadiusVehicle UsedHow OftenItems(s) HauledValueRadiusVehicle UsedHow OftenItems(s) HauledValueRadiusVehicle UsedHow OftenItems(s) HauledValueRadiusVehicle UsedHow OftenWhich Drivers handle these operations?Does the Applicant use air bags in its towing and recovery operations?YesNoIf yes, how many bags?If coverage for equipment is desired, please attach list of equipment with I.D.#s and values.Does the Applicant always use safety chains?YesNoDoes the Applicant, at any time, perform snow plowing?YesNoIf yes, who does the Applicant plow for? Vehicle ScheduleInsured Name:Date:Upload Vehicle and Driver List Drop files here or Or manually fill out belowVehicle #1YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #2YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #3YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #4YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #5YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging LocationVehicle #6YearMakeModelBody TypeVIN#Stated AmountGVWClass CodeOn-Hook LimitDeductibles: CompDeductibles: CollisionDeductibles: On-HookUse of vehicleRadius of operationDescribe tow/specialty equipment separately (rotator, etc.)Garaging Location Driver ListDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceDriver's NameDOBDriver's License #Date of EmploymentStatus (Part-time / Full-time)Commercial Driving ExperienceTow Truck ExperienceHave you identified every possible driver of an insured vehicle including those who may fill in during peak periods and emergencies? (Such as members of households, friends, etc.)?YesNoName of Applicant, understands and agrees that on any proposed addition or substitution of driver, the MVR must be submitted to the insurance company for approval prior to hire.
